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Li X, Abboud R, Kirksey L, Levitin A, Lyden S, Guan J, Gadani S, Kovach C, Quatormoni J, Morar S, Partovi S. Role and Value of Intravascular Ultrasound in the End-Stage Renal Disease Population: A Narrative Review. Ann Vasc Surg 2024; 108:295-306. [PMID: 38960094 DOI: 10.1016/j.avsg.2024.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/22/2024] [Accepted: 04/24/2024] [Indexed: 07/05/2024]
Abstract
Vascular access for hemodialysis is the lifeline for patients with end-stage renal disease (ESRD); therefore, maintenance of the vascular access is of the utmost importance. The dialysis circuit can be complicated by stenosis or thrombosis. In particular, central venous stenosis is frequently encountered in the vascular access of patients with ESRD, and this complication may require endovascular management. Conventional catheter-based venography may be inadequate for identifying dynamic forms of extrinsic compression and intravascular webs associated with these lesions. For these types of access complications, balloon angioplasty remains the first-line intervention, with stenting reserved for selected scenarios. Accurate assessment of the venous configuration is therefore important to ensure an adequate treatment response. Intravascular ultrasound (IVUS) has been shown to be beneficial in lower extremity venous interventions. The use of IVUS in dialysis access interventions is currently limited but may be indicated in selected challenging clinical situations. In this article, we discuss the potential uses of IVUS in the ESRD population based on our institutional experience and on the current literature.
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Affiliation(s)
- Xin Li
- Department of Radiology, Hospital of The University of Pennsylvania, Philadelphia, PA
| | - Rayan Abboud
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH
| | - Levester Kirksey
- Department of Vascular Surgery, The Cleveland Clinic Foundation, Cleveland, OH
| | - Abraham Levitin
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH
| | - Sean Lyden
- Department of Vascular Surgery, The Cleveland Clinic Foundation, Cleveland, OH
| | - Justin Guan
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH
| | - Sameer Gadani
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH
| | - Cassandra Kovach
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Jon Quatormoni
- Department of Vascular Surgery, The Cleveland Clinic Foundation, Cleveland, OH
| | - Satya Morar
- School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Sasan Partovi
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH.
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2
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Wang Y, Lei X, Song X, Li L, Li Q. Implantation of an arteriovenous graft through the peripheral vascular access in the presence of superior vena cava stenosis but a patent azygos vein: A case report. J Vasc Access 2024; 25:1686-1689. [PMID: 37655863 DOI: 10.1177/11297298231197003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
Abstract
Long-term indwelling central venous catheters (CVCs) may cause complications, such as central venous disease (CVD). CVD eliminates the possibility of establishing new arteriovenous access. We herein describe a case in which an arteriovenous graft (AVG) is implanted through the peripheral veins and blood flows back to the patent azygos vein, secondary to superior vena cava stenosis. This shows that if the CVD is correctable or the collateral circulation is an alternative vascular pathway that allows blood to return back to the right atrium, the internal fistula flow is well-balanced with the collateral circulation and there are no clinical symptoms of CVD, an arteriovenous access can be established for the operation. This provides a viable, long-term vascular access option for hemodialysis patients with central venous resource depletion.
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Affiliation(s)
- Yan Wang
- Department of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
- West China School of Nursing, Sichuan University, Chengdu, Sichuan Province, China
| | - Xinyao Lei
- Department of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
- West China School of Nursing, Sichuan University, Chengdu, Sichuan Province, China
| | - Xiaowei Song
- Department of Nephrology, The Third People's Hospital of Chengdu, Chengdu, Sichuan Province, China
| | - Ling Li
- Department of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Qiu Li
- Department of Nephrology, The First People's Hospital of Shuangliu District (West China Airport Hospital of Sichuan University), Chengdu, Sichuan Province, China
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3
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Whitaker L, Sherman N, Ahmed I, Etkin Y. A review of the current recommendations and practices for hemodialysis access monitoring and maintenance procedures. Semin Vasc Surg 2024; 37:133-149. [PMID: 39151993 DOI: 10.1053/j.semvascsurg.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/26/2024] [Accepted: 04/29/2024] [Indexed: 08/19/2024]
Abstract
The growing number of prevalent arteriovenous (AV) accesses has been associated with an increase in the incidence of procedures being performed to maintain patency. To reduce the rate of unnecessary procedures, the 2019 Kidney Disease Outcome Quality Initiative guidelines addended the AV access surveillance recommendations, which includes clinical monitoring and assessment of dialysis adequacy alone. Abnormal clinical findings would necessitate follow-up angiography with or without confirmatory duplex ultrasound. Due to poor patency, increased surveillance schedules have been proposed to identify stenosis early and potentially prevent acute thrombotic events and AV access failure. In this review, we outlined current AV access monitoring and maintenance procedure recommendations, as described by the Centers for Medicare and Medicaid Services and 2019 Kidney Disease Outcome Quality Initiative guidelines. In addition, we highlight the findings of recently published randomized controlled trials that have examined increased surveillance schedules.
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Affiliation(s)
- Litton Whitaker
- Nuvance Health, Danbury Hospital, Danbury, CT; Northwell, 2000 Marcus Avenue, Suite 300, New Hyde Park, NY 11042-1069
| | - Nicole Sherman
- Northwell, 2000 Marcus Avenue, Suite 300, New Hyde Park, NY 11042-1069
| | - Isra Ahmed
- Northwell, 2000 Marcus Avenue, Suite 300, New Hyde Park, NY 11042-1069
| | - Yana Etkin
- Northwell, 2000 Marcus Avenue, Suite 300, New Hyde Park, NY 11042-1069.
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4
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Lok CE, Huber TS, Orchanian-Cheff A, Rajan DK. Arteriovenous Access for Hemodialysis: A Review. JAMA 2024; 331:1307-1317. [PMID: 38497953 DOI: 10.1001/jama.2024.0535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Importance Hemodialysis requires reliable vascular access to the patient's blood circulation, such as an arteriovenous access in the form of an autogenous arteriovenous fistula or nonautogenous arteriovenous graft. This Review addresses key issues associated with the construction and maintenance of hemodialysis arteriovenous access. Observations All patients with kidney failure should have an individualized strategy (known as Patient Life-Plan, Access Needs, or PLAN) for kidney replacement therapy and dialysis access, including contingency plans for access failure. Patients should be referred for hemodialysis access when their estimated glomerular filtration rate progressively decreases to 15 to 20 mL/min, or when their peritoneal dialysis, kidney transplant, or current vascular access is failing. Patients with chronic kidney disease should limit or avoid vascular procedures that may complicate future arteriovenous access, such as antecubital venipuncture or peripheral insertion of central catheters. Autogenous arteriovenous fistulas require 3 to 6 months to mature, whereas standard arteriovenous grafts can be used 2 to 4 weeks after being established, and "early-cannulation" grafts can be used within 24 to 72 hours of creation. The prime pathologic lesion of flow-related complications of arteriovenous access is intimal hyperplasia within the arteriovenous access that can lead to stenosis, maturation failure (33%-62% at 6 months), or poor patency (60%-63% at 2 years) and suboptimal dialysis. Nonflow complications such as access-related hand ischemia ("steal syndrome"; 1%-8% of patients) and arteriovenous access infection require timely identification and treatment. An arteriovenous access at high risk of hemorrhaging is a surgical emergency. Conclusions and Relevance The selection, creation, and maintenance of arteriovenous access for hemodialysis vascular access is critical for patients with kidney failure. Generalist clinicians play an important role in protecting current and future arteriovenous access; identifying arteriovenous access complications such as infection, steal syndrome, and high-output cardiac failure; and making timely referrals to facilitate arteriovenous access creation and treatment of arteriovenous access complications.
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Affiliation(s)
- Charmaine E Lok
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Thomas S Huber
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Dheeraj K Rajan
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- University Medical Imaging Toronto, University Health Network, Toronto, Ontario, Canada
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Patanè D, Morale W, Bonomo S, Failla G, Santonocito S, Camerano F, Arcerito F, Coniglio G, Calcara G, Malfa P, Stefano A. Complex central venous catheter for dialysis: interventional radiology experience in insertion and management of their complications. J Vasc Access 2024; 25:149-157. [PMID: 35674099 DOI: 10.1177/11297298221103209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND CVCs are defined 'complex' when they are inserted through non-conventional accesses or positioned in non-usual sites or substituted by IR endovascular procedures. We report our experience in using diagnostic and interventional radiology techniques for complex CVC insertion and management; we recommend some precautions and techniques that could lead to long-term availability of central venous access and to avoid non-conventional sites CVC insertion. METHODS We retrospectively evaluated 617 patients, between January 2010 and December 2019, (mean age 71 ± 13; male 448/617), treated in our department for insertion of tunnelled CVC for haemodialysis. RESULTS Among 617 patients, 241 cases (39%) are considered 'complex' because they required either a PTA with or without stenting to restore/maintain venous access or had an unusual positioning site or required unconventional access. A direct correlation between CT angiography and PTA (r = 0.95; p-value <0.001) and an inverse correlation between CT angiography and unconventional 'rescue' access (r = -0.92; p-value <0.001) were found. CONCLUSIONS Precise pre-operative planning of treatment in a multidisciplinary setting and diagnostic and interventional radiology procedures knowledge allows reducing complex catheterisms in haemodialysis patient.
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Affiliation(s)
- Domenico Patanè
- Department of Diagnostic and Interventional Radiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Walter Morale
- Department of Nephrology, Ospedale Maggiore, Modica, Via Aldo Moro, Italy
| | - Stefania Bonomo
- Department of Diagnostic and Interventional Radiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Giovanni Failla
- Department of Diagnostic and Interventional Radiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Serafino Santonocito
- Department of Diagnostic and Interventional Radiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Francesco Camerano
- Department of Diagnostic and Interventional Radiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Flavio Arcerito
- Department of Diagnostic and Interventional Radiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Giovanni Coniglio
- Department of Diagnostic and Interventional Radiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Giacomo Calcara
- Department of Diagnostic and Interventional Radiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Pierantonio Malfa
- Department of Diagnostic and Interventional Radiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Alessandro Stefano
- Institute of Molecular Bioimaging and Physiology, National Research Council (IBFM-CNR), Cefalù, Italy
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6
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Echefu G, Stowe I, Lukan A, Sharma G, Basu-Ray I, Guidry L, Schellack J, Kumbala D. Central vein stenosis in hemodialysis vascular access: clinical manifestations and contemporary management strategies. FRONTIERS IN NEPHROLOGY 2023; 3:1280666. [PMID: 38022724 PMCID: PMC10664753 DOI: 10.3389/fneph.2023.1280666] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023]
Abstract
Central venous stenosis is a significant and frequently encountered problem in managing hemodialysis (HD) patients. Venous hypertension, often accompanied by severe symptoms, undermines the integrity of the hemodialysis access circuit. In central venous stenosis, dialysis through an arteriovenous fistula is usually inefficient, with high recirculation rates and prolonged bleeding after dialysis. Central vein stenosis is a known complication of indwelling intravascular and cardiac devices, such as peripherally inserted central catheters, long-term cuffed hemodialysis catheters, and pacemaker wires. Hence, preventing this challenging condition requires minimization of central venous catheter use. Endovascular interventions are the primary approach for treating central vein stenosis. Percutaneous angioplasty and stent placement may reestablish vascular function in cases of elastic and recurrent lesions. Currently, there is no consensus on the optimal treatment, as existing management approaches have a wide range of patency rates.
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Affiliation(s)
- Gift Echefu
- Division of Cardiovascular Medicine, The University of Tennessee Health Science Center, Memphis, TN, United States
| | - Ifeoluwa Stowe
- Department of Internal Medicine, Baton Rouge General Medical Center, Baton Rouge, LA, United States
| | - Abdulkareem Lukan
- Department of Internal Medicine, Advocate Illinois Masonic Medical Center, Chicago, IL, United States
| | - Gaurav Sharma
- Department of Nephrology, AIIMS Rishikesh, Rishikesh, India
| | - Indranill Basu-Ray
- Department of Cardiology, AIIMS Rishikesh, Rishikesh, India
- Department of Cardiovascular Disease, Memphis Veterans Affairs Medical Center, Memphis, TN, United States
| | - London Guidry
- Vascular Clinic of Baton Rouge, Baton Rouge, LA, United States
| | - Jon Schellack
- Vascular Clinic of Baton Rouge, Baton Rouge, LA, United States
| | - Damodar Kumbala
- Vascular Clinic of Baton Rouge, Baton Rouge, LA, United States
- Renal Associates of Baton Rouge, Baton Rouge, LA, United States
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7
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Higgins MCSS, Diamond M, Mauro DM, Kapoor BS, Steigner ML, Fidelman N, Aghayev A, Chamarthy MRK, Dedier J, Dillavou ED, Felder M, Lew SQ, Lockhart ME, Siracuse JJ, Dill KE, Hohenwalter EJ. ACR Appropriateness Criteria® Dialysis Fistula Malfunction. J Am Coll Radiol 2023; 20:S382-S412. [PMID: 38040461 DOI: 10.1016/j.jacr.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 12/03/2023]
Abstract
The creation and maintenance of a dialysis access is vital for the reduction of morbidity, mortality, and cost of treatment for end stage renal disease patients. One's longevity on dialysis is directly dependent upon the quality of dialysis. This quality hinges on the integrity and reliability of the access to the patient's vascular system. All methods of dialysis access will eventually result in dialysis dysfunction and failure. Arteriovenous access dysfunction includes 3 distinct classes of events, namely thrombotic flow-related complications or dysfunction, nonthrombotic flow-related complications or dysfunction, and infectious complications. The restoration of any form of arteriovenous access dysfunction may be supported by diagnostic imaging, clinical consultation, percutaneous interventional procedures, surgical management, or a combination of these methods. This document provides a rigorous evaluation of how variants of each form of dysfunction may be appraised and approached systematically. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Matthew Diamond
- Research Author, Boston Medical Center, Boston, Massachusetts
| | - David M Mauro
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | | | | | - Nicholas Fidelman
- Panel Vice-Chair, University of California San Francisco, San Francisco, California
| | - Ayaz Aghayev
- Brigham & Women's Hospital, Boston, Massachusetts
| | - Murthy R K Chamarthy
- Vascular Institute of North Texas, Dallas, Texas; Commission on Nuclear Medicine and Molecular Imaging
| | - Julien Dedier
- Boston Medical Center, Boston, Massachusetts, Primary care physician
| | - Ellen D Dillavou
- WakeMed Hospital System, Raleigh, North Carolina; Society for Vascular Surgery
| | - Mila Felder
- Advocate Christ Medical Center, Oak Lawn, Illinois; American College of Emergency Physicians
| | - Susie Q Lew
- George Washington University, Washington, District of Columbia; American Society of Nephrology
| | | | - Jeffrey J Siracuse
- Boston University School of Medicine, Boston, Massachusetts; Society for Vascular Surgery
| | - Karin E Dill
- Specialty Chair, Emory University Hospital, Atlanta, Georgia
| | - Eric J Hohenwalter
- Specialty Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
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8
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Harduin LDO, Barroso TA, Guerra JB, Filippo MG, de Almeida LC, de Castro-Santos G, Oliveira FAC, Cavalcanti DET, Procopio RJ, Lima EC, Pinhati MES, dos Reis JMC, Moreira BD, Galhardo AM, Joviliano EE, de Araujo WJB, de Oliveira JCP. Guidelines on vascular access for hemodialysis from the Brazilian Society of Angiology and Vascular Surgery. J Vasc Bras 2023; 22:e20230052. [PMID: 38021275 PMCID: PMC10648056 DOI: 10.1590/1677-5449.202300522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/09/2023] [Indexed: 12/01/2023] Open
Abstract
Chronic kidney disease is a worldwide public health problem, and end-stage renal disease requires dialysis. Most patients requiring renal replacement therapy have to undergo hemodialysis. Therefore, vascular access is extremely important for the dialysis population, directly affecting the quality of life and the morbidity and mortality of this patient population. Since making, managing and salvaging of vascular accesses falls within the purview of the vascular surgeon, developing guideline to help specialists better manage vascular accesses for hemodialysis if of great importance. Thus, the objective of this guideline is to present a set of recommendations to guide decisions involved in the referral, evaluation, choice, surveillance and management of complications of vascular accesses for hemodialysis.
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Affiliation(s)
- Leonardo de Oliveira Harduin
- Universidade Estadual do Estado do Rio de Janeiro - UERJ, Departamento de Cirurgia Vascular, Niterói, RJ, Brasil.
| | | | | | - Marcio Gomes Filippo
- Universidade Federal do Rio de Janeiro - UFRJ, Departamento de Cirurgia, Rio de Janeiro, RJ, Brasil.
| | | | - Guilherme de Castro-Santos
- Universidade Federal de Minas Gerais - UFMG, Escola de Medicina, Departamento de Cirurgia, Belo Horizonte, MG, Brasil.
| | | | | | - Ricardo Jayme Procopio
- Universidade Federal de Minas Gerais - UFMG, Escola de Medicina, Departamento de Cirurgia, Belo Horizonte, MG, Brasil.
| | | | | | | | - Barbara D’Agnoluzzo Moreira
- Universidade Federal do Paraná - UFPR, Hospital de Clínicas, Serviço de Cirurgia Vascular, Curitiba, PR, Brasil.
| | | | - Edwaldo Edner Joviliano
- Universidade de São Paulo - USP, Faculdade de Medicina de Ribeirão Preto - FMRP, Departamento de Anatomia e Cirurgia, Ribeirão Preto, SP, Brasil.
| | - Walter Junior Boim de Araujo
- Universidade Federal do Paraná - UFPR, Hospital de Clínicas, Departamento de Angioradiologia e Cirurgia Endovascular, Curitiba, PR, Brasil.
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9
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Meric M, Oztas DM, Cakir MS, Ulukan MO, Sayin OA, Kilickesmez O, Erdinc I, Rodoplu O, Oteyaka E, Ugurlucan M. A surgical method to be reminded for the treatment of symptomatic ipsilateral central venous occlusions in patients with hemodialysis access: Axillo-axillary venous bypass case report and review of the literature. Vascular 2023; 31:1017-1025. [PMID: 35549494 DOI: 10.1177/17085381221092502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND In this case report, we present two chronic hemodialysis patients with upper extremity swelling due to central venous occlusions together with their clinical presentation, surgical management and brief review of the literature. METHODS The first patient who was a 63-year-old female patient with a history of multiple bilateral arteriovenous fistulas (AVFs) was referred to our clinic. Physical examination demonstrated a functioning right brachio-cephalic AVF, with severe edema of the right arm, dilated venous collaterals, facial edema, and unilateral breast enlargement. In her history, multiple ipsilateral subclavian venous catheterizations were present for sustaining temporary hemodialysis access. The second patient was a 47-year-old male with a history of failed renal transplant, CABG surgery, multiple AV fistula procedures from both extremities, leg amputation caused by peripheral arterial disease, and decreased myocardial functions. He was receiving 3/7 hemodialysis and admitted to our clinic with right arm edema, accompanied by pain, stiffness, and skin hyperpigmentation symptoms ipsilateral to a functioning brachio-basilic AVF. He was not able to flex his arms, elbow, or wrist due to severe edema. RESULTS Venography revealed right subclavian vein stenosis with patent contralateral central veins in the first patient. She underwent percutaneous transluminal angioplasty (PTA) twice with subsequent re-occlusions. After failed attempts of PTA, the patient was scheduled for axillo-axillary venous bypass in order to preserve the AV access function. In second patient, venography revealed right subclavian vein occlusion caused secondary to the subclavian venous catheters. Previous attempts for percutaneously crossing the chronic subclavian lesion failed multiple times by different centers. Hence, the patient was scheduled for axillo-axillary venous bypass surgery. CONCLUSION In case of chronic venous occlusions, endovascular procedures may be ineffective. Since preserving the vascular access function is crucial in this particular patient population, venous bypass procedures should be kept in mind as an alternative for central venous reconstruction, before deciding on ligation and relocation of the AVF.
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Affiliation(s)
- Mert Meric
- Department of Cardiovascular Surgery, Istanbul University Istanbul Medical Faculty, Istanbul, Turkey
| | - Didem Melis Oztas
- Cardiovascular Surgery Clinic, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Semih Cakir
- Radiology Clinic, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Ozer Ulukan
- Department of Cardiovascular Surgery, Istanbul Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Omer Ali Sayin
- Department of Cardiovascular Surgery, Istanbul University Istanbul Medical Faculty, Istanbul, Turkey
| | | | - Ibrahim Erdinc
- Cardiovascular Surgery Clinic, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Orhan Rodoplu
- Cardiovascular Surgery Clinic, Atasehir Florence Nightingale Hospital, Istanbul, Turkey
| | - Emre Oteyaka
- Department of Cardiovascular Surgery, Istanbul Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Murat Ugurlucan
- Department of Cardiovascular Surgery, Istanbul Medipol University Faculty of Medicine, Istanbul, Turkey
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10
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Liu YM, Wei YJ, Lu XQ, Wang YF, Wang P, Liang XH. Catheter-related superior vena cava obstruction: A rare cause of chylothorax in maintenance hemodialysis patients. J Vasc Access 2023; 24:1207-1212. [PMID: 35090360 DOI: 10.1177/11297298211073425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
With the extensive use of dialysis catheters in patients undergoing hemodialysis, superior vena cava (SVC) syndrome has gradually attracted attention in recent years. Chylothorax caused by SVC syndrome is rarely reported. In this paper, we report a case of chylothorax secondary to superior vena cava obstruction (SVCO) in a maintenance hemodialysis patient after multiple dialysis catheter placements. Relieving the SVCO through intravascular intervention could effectively treat chylothorax. In the past fourteen months, no recurrence of symptoms has been observed.
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Affiliation(s)
- Ya-Min Liu
- Blood Purification Center, Institute of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yu-Juan Wei
- Blood Purification Center, Institute of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiao-Qing Lu
- Blood Purification Center, Institute of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yu-Fei Wang
- Blood Purification Center, Institute of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Pei Wang
- Blood Purification Center, Institute of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou, China
| | - Xian-Hui Liang
- Blood Purification Center, Institute of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou, China
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11
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Xu X, Zhuang Y, Zeng J, Cai F, He T, Wu J, Chen C, Zou Z, Zhang X, Lv G. Value of a quantitative model of axillary venous blood flow spectrum for the detection of central venous stenosis in patients undergoing hemodialysis via radiocephalic arteriovenous fistula. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:77. [PMID: 35282095 PMCID: PMC8848436 DOI: 10.21037/atm-22-160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/13/2022] [Indexed: 11/10/2022]
Abstract
Background Central venous stenosis (CVS) of radiocephalic arteriovenous fistula (RCAVF) affects RCAVF function and longevity. Ultrasound screening for CVS is limited by acoustic window. Herein, we analyzed the quantitative axillary venous (AxV) spectrum in hemodialysis patients via RCAVF, and constructed central venous stenosis index (CVSI) model based on the spectrum parameters to early detect resting asymptomatic CVS. Methods From August 2017 to May 2021, stage 5 chronic kidney disease (CKD) patients dialysed via RCAVF at the First Affiliated Hospital of Fujian Medical University were included in this study. No CVS-related symptoms were found and the pulsation at the arteriovenous anastomosis was normal. However, the patients had the sensation of swelling in the ipsilateral upper limb during dialysis; the venous pressure advanced upon the completion of dialysis; or both (n=52). The inclusion criteria were as follows: (I) Ultrasound (US) showed that the temporal phases of the AxV spectrum were “normal”; and (II) CVS was confirmed by digital subtraction angiography (DSA). The exclusion criteria were as follows: (I) stent placement; (II) multiple stenosis; and (III) placement of central venous catheter. A total of 37 patients participated in the analysis. Eighteen patients were included in the CVS group, and 19 cases without CVS were included in the control group. Independent sample t-test was used to screen each parameter of the AxV spectrum, and a CVSI model was constructed by principal component analysis (PCA). The receiver operating characteristic curve (ROC) was applied to analyze the diagnostic value of CVSI. Results According to the independent sample t-test, 9 parameters were found to have statistical significance (all P<0.05); they were analyzed by PCA, and the CVSI model was constructed. The ROC showed that CVSI had diagnostic value for CVS. When the cut-off value of CVSI was 7.13, the maximum value of the Youden index was 0.842, with a sensitivity of 100% and a specificity of 84.2%. Conclusions The CVSI helps to early detect resting asymptomatic CVS and dramatically increases the detection rate of CVS.
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Affiliation(s)
- Xiang Xu
- Department of Ultrasound, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yong Zhuang
- Department of Ultrasound, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jinshu Zeng
- Department of Ultrasound, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Fanggang Cai
- Department of Vascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Tianmin He
- Department of Vascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jie Wu
- Department of Vascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Caiming Chen
- Department of Nephrology, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Zhenhuan Zou
- Department of Nephrology, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Xiaohong Zhang
- Department of Nephrology, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Guorong Lv
- Department of Ultrasound, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China.,Collaborative Innovation Center for Maternal and Infant Health Service Application Technology, Quanzhou Medical College, Quanzhou, China
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12
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Damante MA, Huntoon KM, Schunemann VA, Ikeda DS, Youssef PP. Venous infarction secondary to congestive encephalopathy from central venous occlusive disease in a chronic hemodialysis patient: A case report. Brain Circ 2021; 7:277-280. [PMID: 35071845 PMCID: PMC8757506 DOI: 10.4103/bc.bc_49_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 04/19/2021] [Accepted: 05/27/2021] [Indexed: 11/04/2022] Open
Abstract
Central venous occlusive disease secondary to chronic hemodialysis catheterization rarely progresses to encephalopathy, cerebral infarction, and/or hemorrhage. A 59-year-old male with 15 years of haemodialysis-dependent end-stage renal disease presented with acutely altered mental status, extensor rigidity with left hemiparesis and equal, but small and nonreactive pupils. Magnetic resonance imaging demonstrated infarction and cerebral edema. Cranial angiogram through right brachial artery injection revealed right subclavian vein opacification via a patent AV-fistula and retrograde flow to the right internal jugular vein and superior sagittal sinus secondary to occlusion of the brachiocephalic vein. All cerebral and right upper extremity venous drainage occurred via the contralateral venous outflow tract. Internal carotid artery injections revealed significant venous congestion. Despite successful angioplasty with stenting and resolution of venous flow reversal, the patient failed to recover neurologically. The devastating nature of the presented case emphasizes the need for frequent neurologic evaluation of such patients to avoid catastrophic cerebrovascular injury.
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Affiliation(s)
- Mark A Damante
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kristin M Huntoon
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Victoria A Schunemann
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel S Ikeda
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Patrick P Youssef
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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13
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Wu XW, Zhao XY, Li X, Li JX, Liu ZY, Huang Z, Zhang L, Sima CY, Huang Y, Chen L, Zhou S. Effectiveness of sharp recanalization of superior vena cava-right atrium junction occlusion. World J Clin Cases 2021; 9:3848-3857. [PMID: 34141741 PMCID: PMC8180228 DOI: 10.12998/wjcc.v9.i16.3848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/17/2021] [Accepted: 03/29/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Conventional recanalization techniques may fail in patients with completely occluded superior vena cava (SVC).
AIM To analyze the effectiveness and complications of sharp recanalization for completely occluded SVC.
METHODS This was a retrospective study of patients that underwent puncture and recanalization of the SVC between January 2016 and December 2017 at our hospital. Sharp recanalization was performed using the RUPS-100 system. The patients were followed for 12 mo. The main outcomes were the patency rate of SVC and arteriovenous fistula flow during dialysis.
RESULTS The procedure was successful in all 14 patients (100%). Blood pressure in the distal SVC decreased in all 14 cases (100%) from 26.4 ± 2.7 cmH2O to 14.7 ± 1.3 cmH2O (P < 0.05). The first patency rates of the SVC at 24 h and at 3, 6, 9 and 12 mo after sharp recanalization were 100%, 92.9%, 85.7%, 78.6% and 71.4%, respectively. There were two (14.3%) severe, one (7.1%) moderate and one (7.1%) minor complication. The severe complications included one case of pericardial tamponade and one case of hemothorax.
CONCLUSION The results suggest that sharp recanalization can be an additional tool to extend or renew the use of an occluded upper extremity access for hemodialysis. This could be of use in patients with long-term maintenance hemodialysis in whom the maintenance of central venous access is often a challenge.
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Affiliation(s)
- Xiao-Wen Wu
- Department of Interventional Radiology, Guizhou Cancer Hospital, Guiyang 550000, Guizhou Province, China
| | - Xu-Ya Zhao
- Department of Interventional Radiology, Guizhou Cancer Hospital, Guiyang 550000, Guizhou Province, China
| | - Xing Li
- Department of Interventional Radiology, The Affiliated Hospital of Guizhou Medical University, Guiyang 550000, Guizhou Province, China
| | - Jun-Xiang Li
- Department of Interventional Radiology, Guizhou Cancer Hospital, Guiyang 550000, Guizhou Province, China
| | - Zong-Yang Liu
- Department of Nephrology, The Affiliated Hospital of Guizhou Medical University, Guiyang 550000, Guizhou Province, China
| | - Zhi Huang
- Department of Interventional Radiology, The Affiliated Hospital of Guizhou Medical University, Guiyang 550000, Guizhou Province, China
| | - Ling Zhang
- Department of Nursing, Guizhou Cancer Hospital, Guiyang 550000, Guizhou Province, China
| | - Chong-Yang Sima
- Department of Nephrology, Guizhou Cancer Hospital, Guiyang 550000, Guizhou Province, China
| | - Yu Huang
- Department of Interventional Radiology, Guizhou Cancer Hospital, Guiyang 550000, Guizhou Province, China
| | - Lei Chen
- Department of Interventional Radiology, Guizhou Cancer Hospital, Guiyang 550000, Guizhou Province, China
| | - Shi Zhou
- Department of Interventional Radiology, The Affiliated Hospital of Guizhou Medical University, Guiyang 550000, Guizhou Province, China
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14
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Cakir S, Guzelbey T, Mutlu IN, Kilickesmez O. Comparison of functional patency rates between paclitaxel-eluting versus plain balloon angioplasty in hemodialysis patients with central venous stenosis: An intra-individual comparison study. Ther Apher Dial 2021; 26:185-190. [PMID: 33891365 DOI: 10.1111/1744-9987.13662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 04/07/2021] [Accepted: 04/20/2021] [Indexed: 11/29/2022]
Abstract
Central venous stenosis (CVS) is usually a late-diagnosed clinical entity that is common in hemodialysis patients. It causes various problems ranging from hemodialysis difficulty to loss of the arterio-venous (A-V) fistula. In the present study, we aimed to determine the effect of drug eluting balloon while excluding the influence of other variable factors by evaluating the same individuals with plain and paclitaxel-eluting balloons. This research was a prospective study of 18 symptomatic hemodialysis patients (age 50.9 ± 14.0 years, range 32-72 years; 11 male, 7 female) with CVS who underwent treatment by plain balloon angioplasty (PBA) and paclitaxel-eluting balloon angioplasty (PEBA) in our hospital from January 2016 to June 2017. First, third and sixth month central vein patency rates were compared. The median patency rates of central veins were 109.0 (range: 10-324) days after PBA and 238.5 (range: 157-501) days after PEBA (p < 0.001). There was no statistically significant difference between PBA and PEBA angioplasty in one-month patency (p ˃ 0.05). By contrast, a statistically significant difference was found between 3- and 6-month patency rates (p = 0.031 and p ˂ 0.001, respectively). Kaplan-Meier analysis revealed that the primary cumulative patency rate of PEBA was significantly longer than that of PBA (p ˂ 0.001). In this prospective study, PEBA patency is superior to PBA patency in the treatment of CVS in dialysis patients.
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Affiliation(s)
- Semih Cakir
- Department of Radiology, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Tevfik Guzelbey
- Department of Radiology, Istanbul Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Ilhan N Mutlu
- Department of Radiology, Istanbul Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Ozgur Kilickesmez
- Department of Radiology, Istanbul Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
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15
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Vijayvergiya R, Kaur N, Sahoo SK, Sharma A. Endovascular mechanical thrombectomy and stenting in a case of central vein thrombosis. BMJ Case Rep 2021; 14:14/2/e236508. [PMID: 33602756 PMCID: PMC7896565 DOI: 10.1136/bcr-2020-236508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Central vein stenosis and thrombosis are frequent in patients on haemodialysis for end-stage renal disease. Its management includes anticoagulation, systemic or catheter-directed thrombolysis, mechanical thrombectomy and percutaneous transluminal angioplasty (PTA). Use of mechanical thrombectomy in central vein thrombosis has been scarcely reported. We hereby report a case of right brachiocephalic vein thrombosis with underlying stenosis, which was successfully treated by mechanical thrombectomy followed by PTA and stenting. The patient had a favourable 10 months of follow-up.
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Affiliation(s)
- Rajesh Vijayvergiya
- Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Navjyot Kaur
- Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Saroj K Sahoo
- Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Sharma
- Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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16
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Bittl JA. Dialysis access intervention: Techniques for the interventional cardiologist. Prog Cardiovasc Dis 2021; 65:84-88. [PMID: 33587962 DOI: 10.1016/j.pcad.2021.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/02/2021] [Indexed: 11/16/2022]
Abstract
Interventional cardiologists who treat malfunctioning hemodialysis accesses play an important role in the life of patients with end-stage kidney disease (ESKD). By collaborating with interventional nephrologists who currently perform the bulk of routine access angiographic procedures, interventional cardiologists can fill an important gap in the care of ESKD patients by performing urgent or emergent procedures that fall outside the schedule of an outpatient interventional nephrology laboratory to ensure that hemodialysis patients will not miss a hemodialysis session or get a temporary catheter. This paper reviews the pathophysiology of dialysis access failure and illustrates the catheter-based approaches used by interventional cardiologists to treat malfunctioning dialysis accesses.
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Affiliation(s)
- John A Bittl
- Interventional Cardiology Program, AdventHealth Ocala, Ocala, Florida 34474, United States of America.
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17
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Mirza MH, Schwertner A, Kohlbrenner R, Dowd CF, Narsinh KH. Intracranial hemorrhage due to central venous occlusion from hemodialysis access: A case report. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2021; 24. [PMID: 33796444 PMCID: PMC8009337 DOI: 10.1016/j.inat.2020.101081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Central venous stenosis in hemodialysis patients rarely causes venous hypertension and intracranial hemorrhage. A 54 year-old male with right arm arteriovenous fistula was transferred to our institution in a comatose state following right parietal venous infarction. Fistulography showed right brachiocephalic vein (BCV) occlusion with reflux into the right transverse sinus and obstruction of left internal jugular vein outflow due to the styloid process. Balloon venoplasty of the right BCV occlusion failed to improve the patient's status because of the delayed diagnosis. Headaches and neurologic symptoms in hemodialysis patients can herald intracranial hypertension due to central venous occlusion and needs prompt assessment with fistulography.
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Affiliation(s)
- Mohammed H Mirza
- Department of Radiology, University of Illinois College of Medicine, Peoria, IL, United States
| | - Adam Schwertner
- Department of Radiology, University of Colorado Denver School of Medicine, Denver, CO, United States
| | - Ryan Kohlbrenner
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA, United States
| | - Christopher F Dowd
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA, United States
| | - Kazim H Narsinh
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA, United States
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18
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Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, Allon M, Asif A, Astor BC, Glickman MH, Graham J, Moist LM, Rajan DK, Roberts C, Vachharajani TJ, Valentini RP. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis 2020; 75:S1-S164. [PMID: 32778223 DOI: 10.1053/j.ajkd.2019.12.001] [Citation(s) in RCA: 1018] [Impact Index Per Article: 254.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 12/09/2019] [Indexed: 02/07/2023]
Abstract
The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.
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19
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Burbelko M. [Thoracic Central Venous Occlusive Disease and Haemodialysis Access]. Zentralbl Chir 2020; 145:473-480. [PMID: 32120444 DOI: 10.1055/a-1014-3538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Benign central venous thoracic occlusion is a frequent issue in haemodialysis patients. Symptomatic stenosis affects quality of life and can cause dysfunction of arteriovenous access or make it impossible to implant a haemodialysis catheter. Common risk factors for the development of the occlusions are central venous catheters and cardiac rhythm devices. The gold standard for diagnosis is venous angiography. Treatment of asymptomatic lesions can lead to clinical deterioration and should be avoided. The primary method of treatment for symptomatic patients is endovascular therapy. Repeat balloon angioplasty is a standard therapy. In case of elastic recoiling or early recurrence, placement of bare metal stent or stent graft could be considered. Surgical options should be preserved only for refractory cases. Further randomised trials are needed to prove the efficacy of new devices, such as dedicated venous stents and drug coated balloons.
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Affiliation(s)
- Michael Burbelko
- Institut für Radiologie und Interventionelle Therapie, Vivantes Klinikum im Friedrichshain, Berlin, Deutschland
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20
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Park HS, Choi J, Baik JH. Central venous disease in hemodialysis patients. Kidney Res Clin Pract 2019; 38:309-317. [PMID: 31387161 PMCID: PMC6727898 DOI: 10.23876/j.krcp.19.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/31/2019] [Accepted: 05/31/2019] [Indexed: 01/18/2023] Open
Abstract
Central venous disease (CVD) is difficult to treat and often resistant to treatment. In CVD, hemodialysis vascular access should sometimes be abandoned, or in serious cases, the patient's life may be threatened. Therefore, prevention is ideal. However, as the prevalence of chronic kidney disease (CKD) has increased steadily with population aging, CKD patients with a peripherally inserted central catheter (PICC) are encountered frequently. PICCs can cause CVD, and the basilic vein, which is regarded as the important last option for native arteriovenous fistula (AVF) creation in end-stage renal disease (ESRD) patients, is destroyed frequently after its use as the entry site of PICC. The most well-established risk factors for CVD are a history of central venous catheter (CVC) insertion and its duration of use. Therefore, to reduce the incidence of CVD, catheterization in the central vein (CV) should be minimized, along with its duration of use. In this review, we will first explain the basic territories of the CV and introduce its pathophysiology, clinical features, and advanced treatment options. Finally, we will emphasize prevention of CVD.
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Affiliation(s)
- Hoon Suk Park
- Division of Nephrology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joonsung Choi
- Department of Radiology, St. Vincent's Hospital, School of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jun Hyun Baik
- Department of Radiology, St. Vincent's Hospital, School of Medicine, The Catholic University of Korea, Suwon, Korea
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21
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Nassar GM, Beathard G. Exploring correlations between anatomic characteristics of dialysis arteriovenous fistula stenosis and arteriovenous fistula blood flow rate (Qa). J Vasc Access 2019; 21:60-65. [DOI: 10.1177/1129729819851323] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Radiologic justification for endovascular treatment of a dialysis arteriovenous fistula circuit stenosis is currently based on ⩾50% severity. However, the clinical significance of any given stenosis is not always clear. The minimum luminal diameter of any stenotic lesion in the arteriovenous fistula circuit might exert a more predictive effect on the arteriovenous fistula blood flow rate (Qa). Methods: To investigate relationships between anatomic parameters of stenosis and Qa, this study was conducted in a cohort of patients with a variety of arteriovenous fistula stenotic lesions. The goals were to determine (1) the degree of correlation between arteriovenous fistula stenosis estimated during the procedure, and that which is measured, and (2) the correlations between two anatomic stenosis parameters (percent stenosis and stenosis minimum luminal diameter) and Qa. Results: The cohort comprised 113 patients. Only a moderate correlation between estimated and measured stenosis was seen. A correlation between measured stenosis and Qa for the whole cohort was not seen, but a weak correlation between estimated stenosis and Qa was seen. Correlations between stenosis minimum luminal diameter and Qa were superior. The superiority of stenosis minimum luminal diameter to percent stenosis in correlating with a Qa of <500 mL/h was also demonstrated by receiver operating characteristics curve analysis. Stenosis minimum luminal diameter cutoffs of ⩽2.5 mm or >4 mm seemed to have a good predictive value of Qa. Conclusions: Percent stenosis determination is fraught with uncertainty and exhibits a weak correlation with Qa. Compared with percent stenosis, the minimum luminal diameter of the stenosis demonstrates a superior correlation with Qa.
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Affiliation(s)
- George M Nassar
- Dialysis Access Management Centers, Nephrology Dialysis and Transplantation Associates, The Kidney Institute & Houston Methodist Hospital, Weill Cornell University, Houston, TX, USA
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22
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Gameiro J, Ibeas J. Factors affecting arteriovenous fistula dysfunction: A narrative review. J Vasc Access 2019; 21:134-147. [PMID: 31113281 DOI: 10.1177/1129729819845562] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Vascular access dysfunction is one of the most important causes of morbidity and mortality in haemodialysis patients, contributing to up to one third of hospitalisations and accounting for a significant amount of the health care costs of these patients. In the past decades, significant scientific advances in understanding mechanisms of arteriovenous fistula maturation and failure have contributed to an increase in the amount of research into techniques for creation and strategies for arteriovenous fistula dysfunction prevention and treatment, in order to improve patient care and outcomes. The aim of this review is to describe the pathogenesis of vascular access failure and provide a comprehensive analysis of the associated risk factors and causes of vascular access failure, in order to interpret possible future therapeutic approaches. Arteriovenous fistula failure is a multifactorial process resulting from the combination of upstream and downstream events with consequent venous neo-intimal hyperplasia and/or inadequate outward remodelling. Inflammation appears to be central in the biology of arteriovenous fistula dysfunction but important triggers still need to be revealed. Given the significant association of arteriovenous fistula failure and patient's prognosis, it is therefore imperative to further research in this area in order to improve prevention, surveillance and treatment, and ultimately patient care and outcomes.
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Affiliation(s)
- Joana Gameiro
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Lisboa, Portugal
| | - Jose Ibeas
- Nephrology Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
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23
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Spanish Clinical Guidelines on Vascular Access for Haemodialysis. Nefrologia 2018; 37 Suppl 1:1-191. [PMID: 29248052 DOI: 10.1016/j.nefro.2017.11.004] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 06/21/2017] [Indexed: 12/26/2022] Open
Abstract
Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.
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24
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Dolmatch BL, Gurley JC, Baskin KM, Nikolic B, Lawson JH, Shenoy S, Saad TF, Davidson I, Baerlocher MO, Cohen EI, Dariushnia SR, Faintuch S, d’Othee BJ, Kinney TB, Midia M, Clifton J. Society of Interventional Radiology Reporting Standards for Thoracic Central Vein Obstruction: Endorsed by the American Society of Diagnostic and Interventional Nephrology (ASDIN), British Society of Interventional Radiology (BSIR), Canadian Interventional Radiology Association (CIRA), Heart Rhythm Society (HRS), Indian Society of Vascular and Interventional Radiology (ISVIR), Vascular Access Society of the Americas (VASA), and Vascular Access Society of Britain and Ireland (VASBI). J Vasc Access 2018; 20:114-122. [DOI: 10.1177/1129729818791409] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Bart L Dolmatch
- Department of Interventional Radiology, Palo Alto Medical Foundation, Palo Alto, CA, USA
| | - John C Gurley
- Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Kevin M Baskin
- Department of Radiology, Advanced Interventional Institute, Pittsburgh, PA, USA
| | - Boris Nikolic
- Department of Radiology, Stratton Medical Center, Albany, NY, USA
| | - Jeffrey H Lawson
- Division of Vascular and Endovascular Surgery, Duke University, Durham, NC, USA
| | - Surendra Shenoy
- Department of Radiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Theodore F Saad
- Department of Radiology, St. Francis Hospital, Nephrology Associates, Wilmington, DE, USA
| | - Ingemar Davidson
- Department of Radiology, Tulane University, New Orleans, LA, USA
| | - Mark O Baerlocher
- Department of Interventional Radiology, Royal Victoria Hospital, Barrie, ON, Canada
| | - Emil I Cohen
- Department of Radiology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Sean R Dariushnia
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-Guided Medicine, Emory University School of Medicine, GA, USA
| | - Salomão Faintuch
- Division of Interventional Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Thomas B Kinney
- Department of Radiology, University of California, San Diego Medical Center, San Diego, CA, USA
| | - Mehran Midia
- Department of Interventional Radiology, McMaster University, Hamilton, ON, Canada
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Dolmatch BL, Gurley JC, Baskin KM, Nikolic B, Lawson JH, Shenoy S, Saad TF, Davidson I, Baerlocher MO, Cohen EI, Dariushnia SR, Faintuch S, Janne d’Othee B, Kinney TB, Midia M, Clifton J, Baerlocher MO, Baskin K, Clifton J, Dalley A, Dariushnia S, Davidson I, Dolmatch B, Gurley J, Haskal Z, Journeycake J, Lawson J, McLennan G, Nikolic B, Ramsburg D, Ross J, Saad T, Shenoy S, Spencer B, Thompson D, Walker TG, Walser E. Society of Interventional Radiology Reporting Standards for Thoracic Central Vein Obstruction. J Vasc Interv Radiol 2018; 29:454-460.e3. [DOI: 10.1016/j.jvir.2017.12.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 12/14/2017] [Accepted: 12/14/2017] [Indexed: 10/17/2022] Open
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Mansour M, Kamper L, Altenburg A, Haage P. Radiological Central Vein Treatment in Vascular Access. J Vasc Access 2018. [DOI: 10.1177/112972980800900203] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
In the last decades, the percutaneous interventional approach for the treatment of central venous obstructions (CVO) has become increasingly popular as the treatment of first choice because of its minimal invasiveness and reported success rates. CVOs are caused by a diverse spectrum of diseases which can be broadly categorized into two principal eliciting genera, either benign or malignant obstructions. The large group of benign venous obstructions includes the increasing number of end-stage renal disease patients with vascular access related complications. Due to the invasiveness and complexity of thoracic surgery for benign CVOs, the less invasive percutaneous interventional therapy can generally be considered the preferred treatment option. Initially, the radiological intervention consisted of balloon angioplasty alone, subsequently additional stent placement was applied. This was advocated as either primary placement or secondary in cases of elastic recoil or residual stenosis after percutaneous transluminal angioplasty (PTA). The efficacy of angioplasty of CVO in patients with vascular accesses, either with or without stenting, has been addressed by various studies. Overall, reports indicate an initial technical and clinical success rate above 95% and satisfactory patency rates. However, systematic follow-up and frequent re-interventions are necessary to maintain vascular patency to achieve long-term success.
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Affiliation(s)
- M. Mansour
- Department of Diagnostic and Interventional Radiology, HELIOS Klinikum Wuppertal, University Hospital Witten/Herdecke, Wuppertal - Germany
| | - L. Kamper
- Department of Diagnostic and Interventional Radiology, HELIOS Klinikum Wuppertal, University Hospital Witten/Herdecke, Wuppertal - Germany
| | - A. Altenburg
- Department of Diagnostic and Interventional Radiology, HELIOS Klinikum Wuppertal, University Hospital Witten/Herdecke, Wuppertal - Germany
| | - P. Haage
- Department of Diagnostic and Interventional Radiology, HELIOS Klinikum Wuppertal, University Hospital Witten/Herdecke, Wuppertal - Germany
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Allon M, Brouwer-Maier DJ, Abreo K, Baskin KM, Bregel K, Chand DH, Easom AM, Mermel L, Mokrzycki MH, Patel PR, Roy-Chaudhury P, Shenoy S, Valentini RP, Wasse H. Recommended Clinical Trial End Points for Dialysis Catheters. Clin J Am Soc Nephrol 2018; 13:495-500. [PMID: 28729382 PMCID: PMC5967684 DOI: 10.2215/cjn.12011116] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Central venous catheters are used frequently in patients on hemodialysis as a bridge to a permanent vascular access. They are prone to frequent complications, including catheter-related bloodstream infection, catheter dysfunction, and central vein obstruction. There is a compelling need to develop new drugs or devices to prevent central venous catheter complications. We convened a multidisciplinary panel of experts to propose standardized definitions of catheter end points to guide the design of future clinical trials seeking approval from the Food and Drug Administration. Our workgroup suggests diagnosing catheter-related bloodstream infection in catheter-dependent patients on hemodialysis with a clinical suspicion of infection (fever, rigors, altered mental status, or unexplained hypotension), blood cultures growing the same organism from the catheter hub and a peripheral vein (or the dialysis bloodline), and absence of evidence for an alternative source of infection. Catheter dysfunction is defined as the inability of a central venous catheter to (1) complete a single dialysis session without triggering recurrent pressure alarms or (2) reproducibly deliver a mean dialysis blood flow of >300 ml/min (with arterial and venous pressures being within the hemodialysis unit parameters) on two consecutive dialysis sessions or provide a Kt/V≥1.2 in 4 hours or less. Catheter dysfunction is defined only if it persists, despite attempts to reposition the patient, reverse the arterial and venous lines, or forcefully flush the catheter. Central vein obstruction is suspected in patients with >70% stenosis of a central vein by contrast venography or the equivalent, ipsilateral upper extremity edema, and an existing or prior history of a central venous catheter. There is some uncertainty about the specific criteria for these diagnoses, and the workgroup has also proposed future high-priority studies to resolve these questions.
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Affiliation(s)
- Michael Allon
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Caro Monroig A, Reddy SN, Chick JFB, Sammarco TE, Chittams JL, Trerotola SO. Fistulography of a Patent Hemodialysis Access: When Not to Treat and Implications for Establishing a Nontreatment Rate. J Vasc Interv Radiol 2018; 29:376-382. [PMID: 29395899 DOI: 10.1016/j.jvir.2017.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 10/23/2017] [Accepted: 11/13/2017] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To establish a rate of nonintervention in patients referred for hemodialysis access fistulography and to report clinical and fistulographic variables associated with nonintervention. MATERIALS AND METHODS Encounters for fistulography were reviewed from 2001 to 2016 to determine annual rates of nontreatment over 15 years. Next, an access database was used to retrospectively identify patients undergoing fistulography from 2010 to 2016. Patients who underwent fistulography without intervention (angioplasty or stent placement) served as the nontreatment group (NTG; n = 76). Patients who underwent fistulography with intervention served as the control group (CG; n = 77). Patients with thrombosed accesses were excluded. Clinical indications for intervention and physical examination findings were correlated with fistulography. Need for subsequent percutaneous intervention was recorded. RESULTS Annual nontreatment rates ranged from 3% to 14% (median, 10%). Preprocedure thrill was encountered in 45 patients in the NTG (59%) vs 6 in the CG (7.8%; P < .01). Aneurysm as indication for fistulography was more common in the NTG than the CG (19 [25%] vs 4 [5%]; P < .01). The NTG had a higher proportion of aneurysms noted on fistulography as well (38 [50%] vs 19 [25%]; P < .01). The CG had a higher proportion of patients needing subsequent percutaneous intervention vs the NTG (73 [96%] vs 38 [50%]; P < .001). CONCLUSIONS A suggested nonintervention rate for hemodialysis access fistulography is 10%. Patients in the NTG were more likely to have a thrill on physical examination or to present with aneurysms as the clinical indicator. NTG patients were less likely to require subsequent percutaneous intervention.
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Affiliation(s)
- Angeliz Caro Monroig
- Department of Radiology, Division of Interventional Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, 1 Silverstein, 3400 Spruce St., Philadelphia, PA 19104
| | - Shilpa N Reddy
- Department of Radiology, Division of Interventional Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, 1 Silverstein, 3400 Spruce St., Philadelphia, PA 19104
| | - Jeffrey Forris Beecham Chick
- Department of Radiology, Division of Interventional Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, 1 Silverstein, 3400 Spruce St., Philadelphia, PA 19104; Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Therese E Sammarco
- Biostatistics Consulting Unit, Office of Nursing Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jesse L Chittams
- Biostatistics Consulting Unit, Office of Nursing Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott O Trerotola
- Department of Radiology, Division of Interventional Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, 1 Silverstein, 3400 Spruce St., Philadelphia, PA 19104.
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29
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Preoperative management of arteriovenous fistula (AVF) for hemodialysis. J Vasc Access 2017; 18:451-463. [PMID: 29027182 DOI: 10.5301/jva.5000771] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2017] [Indexed: 11/20/2022] Open
Abstract
Native arteriovenous fistula (AVF) is the favorite access for hemodialysis (HD). The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) recommends its creation in most patients with renal failure. Unfortunately, intensive efforts to promote native AVF in patients with marginal vessels have increased the rate of primary fistula failure. A non-functioning fistula prompts the use of central venous catheter (CVC) that, unlike AVF, has been associated with an increased risk of morbidity and mortality among patients receiving HD. We believe that successful and timely AVF placement relies on the development of a multidisciplinary integrated preoperative program divided into five stages: (i) management of patients with advanced chronic kidney disease (CKD), (ii) management of preoperative risk factors for AVF failure, (iii) planning of native AVF, (iv) assessment of patient eligibility and (v) preoperative vascular mapping. Focusing specifically on native AVF, we review scientific evidence regarding preoperative management of this vascular access in order to favor construction of long-term functioning fistula minimizing development of severe complications.
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Ehrie JM, Sammarco TE, Chittams JL, Trerotola SO. Unmasking of Previously Asymptomatic Central Venous Stenosis following Percutaneous Transluminal Angioplasty of Hemodialysis Access. J Vasc Interv Radiol 2017; 28:1409-1414. [DOI: 10.1016/j.jvir.2017.07.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 07/07/2017] [Accepted: 07/07/2017] [Indexed: 11/30/2022] Open
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Renaud CJ, Turmel-Rodrigues L. Doing Less rather than More in Asymptomatic Central Vein Stenosis: The Debate Continues. J Vasc Interv Radiol 2017; 28:1415-1416. [PMID: 28941517 DOI: 10.1016/j.jvir.2017.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 07/30/2017] [Indexed: 11/27/2022] Open
Affiliation(s)
- Claude J Renaud
- Department of Medicine, Division of Nephrology, Khoo Teck Puat Hospital, Singapore 768828, Singapore.
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Abstract
While imaging of the central venous system has traditionally been performed with conventional venography, MR venography (MRV) has emerged as an important modality as techniques and validation studies have evolved over time. While magnetic resonance angiography has a very robust representation in the literature, the proportion representing MRV is relatively sparse. The purpose of this article is to review the indications, techniques, and dedicated studies validating MRV of the central veins of the thorax.
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Kitrou PM, Papadimatos P, Spiliopoulos S, Katsanos K, Christeas N, Brountzos E, Karnabatidis D. Paclitaxel-Coated Balloons for the Treatment of Symptomatic Central Venous Stenosis in Dialysis Access: Results from a Randomized Controlled Trial. J Vasc Interv Radiol 2017; 28:811-817. [PMID: 28434662 DOI: 10.1016/j.jvir.2017.03.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 03/04/2017] [Accepted: 03/10/2017] [Indexed: 02/05/2023] Open
Abstract
PURPOSE To compare the clinically-assessed intervention-free period (IFP) of paclitaxel-coated balloon (PCB) vs conventional balloon angioplasty (CBA) for the treatment of symptomatic central venous stenosis (CVS) in dialysis access. MATERIALS AND METHODS Within 20 months, 40 dialysis patients (19/40 arteriovenous fistulae [AVFs] and 21/40 arteriovenous grafts [AVGs]) were randomized to undergo angioplasty either with a PCB (PCB group, n = 20; 14/20 male; age: 56.7) or CBA (CBA group, n = 20; 15/20 male; age: 57). There were 15/20 restenotic lesions in PCB group and 12/20 in CBA group. In 25/40 cases, patients had an ipslateral catheter insertion in the past. Primary endpoint was clinically-assessed intervention-free period (IFP) of the treated segment at 6 months, while secondary endpoints included complication rates during follow-up period and identification of factors influencing IFP. RESULTS Median IFP was significantly better in PCB group (PCB group: 179 days, vs CBA group: 124.5 days, P = .026). Mean follow-up period was 180 days (range, 5-479). There was no significant difference between AVGs and AVFs (P = .17), treatment of de novo vs restenotic lesions (P = .33), or prior presence of catheter insertion (P = .21). No complications were observed. In restenotic lesions in PCB group, longitudinal comparison between treatments also showed a significant difference in favor of PCB treatment (median IFP in PCB* group 177 vs 91 days in CBA* group; P = .01). CONCLUSIONS In this prospective study, PCB had significantly better results compared with CBA for the treatment of symptomatic central venous stenosis in dialysis access. Retrospective longitudinal comparison of treatments in the same patients also showed a significant difference in favor of PCBs.
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Affiliation(s)
- Panagiotis M Kitrou
- Interventional Radiology Department, Patras University Hospital, Patras, Greece.
| | | | - Stavros Spiliopoulos
- Second Department of Radiology, Division of Interventional Radiology, Attikon University General Hospital, Athens, Greece
| | | | - Nicolaos Christeas
- Interventional Radiology Department, Patras University Hospital, Patras, Greece
| | - Elias Brountzos
- Second Department of Radiology, Division of Interventional Radiology, Attikon University General Hospital, Athens, Greece
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Massara M, De Caridi G, Alberti A, Volpe P, Spinelli F. Symptomatic superior vena cava syndrome in hemodialysis patients: mid-term results of primary stenting. Semin Vasc Surg 2017; 29:186-191. [PMID: 28779785 DOI: 10.1053/j.semvascsurg.2017.05.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This clinical report details the results of endovascular treatment of symptomatic superior vena cava syndrome due to central vein stenosis or obstruction (CVSO) by stent angioplasty in patients with dialysis-dependent end-stage renal disease. A 3-year retrospective review of two institutional registries identified 25 chronic hemodialysis patients (17 men, 8 women) affected by CVSO who received endovascular treatment. The majority of the patients (n = 19) presented with symptomatic arm, breast, and facial swelling; and 6 patients presented with dialysis-access dysfunction and venous-line hypertension. The etiology of CVSO was before central venous catheter in all but 2 patients. Venography showed 19 cases of stenosis (4 stenoses of superior vena cava, 3 brachiocephalic, 10 subclavian, and 2 axillary veins) and 6 occlusions of the superior vena cava. After percutaneous transluminal angioplasty and primary stent angioplasty, there was an immediate regression of symptoms and arteriovenous fistula preservation in 21 cases; 4 patients received a new arteriovenous fistula after interventional treatment. No procedural major complications or patient deaths occurred. During the follow-up period, we recorded a primary patency rate of 95%, 80%, and 70%, respectively, at 6, 12, and 18 months; and a secondary patency rate of 100%, 95%, and 90%, respectively, at 6, 12, and 18 months. In conclusion, endovascular treatment with primary stenting has proven to be a durable treatment option for hemodialysis patients with CVSO, and this treatment should be considered before dialysis access placement in patients with catheter-induced central vein obstruction.
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Affiliation(s)
- Mafalda Massara
- Vascular Surgery Unit, Bianchi-Melacrino-Morelli Hospital, Via Melacrino 1, Reggio Calabria, Italy; Vascular Surgery Unit, University of Messina, Messina, Italy.
| | | | - Antonino Alberti
- Vascular Surgery Unit, Bianchi-Melacrino-Morelli Hospital, Via Melacrino 1, Reggio Calabria, Italy
| | - Pietro Volpe
- Vascular Surgery Unit, Bianchi-Melacrino-Morelli Hospital, Via Melacrino 1, Reggio Calabria, Italy
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Treatment of central venous in-stent restenosis with repeat stent deployment in hemodialysis patients. J Vasc Access 2017; 18:214-219. [DOI: 10.5301/jva.5000705] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2017] [Indexed: 01/24/2023] Open
Abstract
Purpose To report patency rates for stent deployment for treatment of in-stent stenosis of the central veins of the chest in hemodialysis patients. Materials and Methods A retrospective analysis was performed on 29 patients who underwent 35 secondary percutaneous transluminal stent (PTS) deployments for in-stent stenosis within the central veins that were refractory to angioplasty and ipsilateral to a functioning hemodialysis access (in-stent PTS group). For comparison, patency data were acquired for 47 patients who underwent 78 successful percutaneous transluminal angioplasty (PTA) procedures for in-stent stenosis (in-stent PTA group) and 55 patients who underwent 55 stent deployments within native central vein stenosis refractory to angioplasty (native vein PTS group). Results The 3-, 6-, and 12-month primary lesion patency for the in-stent PTS group was 73%, 57%, and 32%, respectively. The 3-, 6-, and 12-month primary patency for the in-stent PTA group was 70%, 38%, and 17% and for the native vein PTS group was 78%, 57%, and 26%, which were similar to the in-stent PTS group (p = 0.20 and 0.41, respectively). The 3-, 6-, and 12-month secondary access patency was 91%, 73%, and 65% for the in-stent PTS group. Sub-analysis of the in-stent PTS group revealed no difference in primary (p = 0.93) or secondary patency rates (p = 0.27) of bare metal stents (n = 23) compared with stent grafts (n = 12). Conclusions Stent deployment for central vein in-stent stenosis refractory to angioplasty was associated with reasonable patency rates, which were similar to in-stent PTA and native vein PTS.
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Huang Y, Chen B, Tan G, Cheng G, Zhang Y, Li J, Yang J. The feasibility and safety of a through-and-through wire technique for central venous occlusion in dialysis patients. BMC Cardiovasc Disord 2016; 16:250. [PMID: 27923353 PMCID: PMC5142130 DOI: 10.1186/s12872-016-0411-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 11/14/2016] [Indexed: 11/30/2022] Open
Abstract
Background To retrospectively compare the operation time, success rate and efficacy between unidirectional and bidirectional procedures in the treatment of central venous occlusion diseases (CVOD), assess the advantages of the bidirectional approach, and determine the characteristics of CVOD appropriate for the bidirectional approach treatment. Methods A total of 49 patients who underwent endovascular interventions with all relevant data between January 2011 and December 2015 at the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China, were included in this retrospective study, and were categorized into two groups: the 19 patients in group 1 had undergone percutaneous transluminal venoplasty (PTV) via a conventional technique (unidirectional procedure from the vein distal or proximal to the obstructive lesion), and the 30 in group 2 had undergone flossing wire technique (bidirectional procedure from femoral vein and the vein distal to obstructive lesion and using a flossing wire technique). The technical success rate, the fluoroscopy time in the procedure, perioperative complications, and patency were evaluated retrospectively. Results Compared with group 1, group 2 had a higher initial technical success rate (83.33% vs. 47.36%, p = 0.012) but a shorter fluoroscopy time (82.6 ± 26.1 vs. 116.1 ± 42.1, p = 0.048). Receiver operating characteristic (ROC) analysis indicated that a lesion with a length of 6.5 cm was the best predictor of technique success (p = 0.02) in group 1, but no cut-off value was identified for group 2. There were no significant differences in perioperative complications between these two groups. The complication rates were 31.58% (6/19) in group 1 and 6.67% (2/30) in group 2, (p = 0.043), respectively. No significant difference was observed between these two groups with respect to the stent patency rate. Conclusion Compared with the conventional technique, the flossing wire technique has a higher success rate, shorter fluoroscopy time, fewer complications and similar patency rate. It is a feasible treatment for CVOD, especially for long obstructive lesions.
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Affiliation(s)
- Yonghui Huang
- The Department of Interventional Radiology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan Road II, Guangzhou, 510080, China.
| | - Bing Chen
- The Department of Interventional Radiology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan Road II, Guangzhou, 510080, China
| | - Guosheng Tan
- The Department of Interventional Radiology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan Road II, Guangzhou, 510080, China
| | - Gang Cheng
- The Department of Interventional Radiology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan Road II, Guangzhou, 510080, China
| | - Yi Zhang
- The Department of Interventional Radiology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan Road II, Guangzhou, 510080, China
| | - Jiaping Li
- The Department of Interventional Radiology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan Road II, Guangzhou, 510080, China
| | - Jianyong Yang
- The Department of Interventional Radiology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan Road II, Guangzhou, 510080, China.
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Abstract
Central venous stenosis or occlusion is a common and vexing problem in patients undergoing hemodialysis. Typical presenting symptoms include arm swelling and prolonged bleeding after hemodialysis. Despite multiple treatment approaches, these stenoses tend to recur and progress over time. A thorough preprocedure evaluation, methodical procedural approach and awareness of potential complications are all essential to try to preserve vascular access and improve patients' quality of life.
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Affiliation(s)
- Masahiro Horikawa
- Dotter Interventional Institute, Oregon Health and Science University, Portland, OR
| | - Keith B Quencer
- Division of Interventional Radiology, Department of Radiology, University of California, San Diego, San Diego, CA; Dotter Interventional Institute, Oregon Health and Science University, Portland, OR.
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38
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Krishna VN, Eason JB, Allon M. Central Venous Occlusion in the Hemodialysis Patient. Am J Kidney Dis 2016; 68:803-807. [DOI: 10.1053/j.ajkd.2016.05.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 05/27/2016] [Indexed: 11/11/2022]
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Creating Arteriovenous Fistulas in Patients with Chronic Central Venous Obstruction. J Vasc Access 2016; 17:239-42. [DOI: 10.5301/jva.5000507] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2015] [Indexed: 11/20/2022] Open
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40
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Quaretti P, Galli F, Moramarco LP, Corti R, Leati G, Fiorina I, Tinelli C, Montagna G, Maestri M. Stent Grafts Provided Superior Primary Patency for Central Venous Stenosis Treatment in Comparison with Angioplasty and Bare Metal Stent: A Retrospective Single Center Study on 70 Hemodialysis Patients. Vasc Endovascular Surg 2016; 50:221-30. [PMID: 27097842 DOI: 10.1177/1538574416639149] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To compare patency in dialysis patients following different endovascular treatment of symptomatic central venous stenosis. MATERIALS AND METHODS A 10-year retrospective evaluation in 70 patients (32 men) dialyzing through vascular access (33, 47%) and tunneled catheters (37, 53%) was made. Three cohorts were compared: angioplasty alone (22), bare metal stent (28), and stent graft (20). Patencies were described with Kaplan-Meier method, and Cox uni- and multivariate models were analyzed to find factors associated. RESULTS All patients had a favorable anatomical and clinical outcome. Restenosis occurred in 22 (31%) of 70 patients requiring 41 additional interventions; 34 of 70 patients died (median follow-up 19.4 months). Primary patency at 3, 6, 12, and 24 months was 100%, 100%, 100%, and 84% for stent graft versus 90%, 79%, 58%, and 43% for angioplasty (P = .014) versus 84%, 80%, 75%, and 46% for bare-metal stent (P = .062). The overall comparison was more favorable for stent graft (P = .020) when the sites of lesions were matched. Patencies for angioplasty and bare-metal stents were equivalent (P = .141). A lower risk of restenosis (hazard rate [HR] 0.20, confidence interval [CI] 0.06-0.7) and fewer reinterventions (P < .01) were associated with stent graft, whereas age (HR 1.04, CI 1.001-1.08) and cardiovascular disease (HR 2.26, CI 1.06-4.84) influenced the overall survival. No difference in assisted primary patency was found. CONCLUSION Stent graft seems to improve primary patency for central venous stenosis and requires fewer reinterventions in a dialysis population with a high prevalence of long-term catheters.
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Affiliation(s)
- Pietro Quaretti
- Unit of Interventional Radiology-Radiology Department, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Franco Galli
- Nephrology and Dialysis, IRCCS Fondazione Salvatore Maugeri, Pavia, Italy
| | - Lorenzo Paolo Moramarco
- Unit of Interventional Radiology-Radiology Department, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Riccardo Corti
- Radiology Department, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Giovanni Leati
- Radiology Department, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Ilaria Fiorina
- Radiology Department, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Carmine Tinelli
- Clinical Epidemiology and Biometric Unit, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Giovanni Montagna
- Nephrology and Dialysis, IRCCS Fondazione Salvatore Maugeri, Pavia, Italy
| | - Marcello Maestri
- Department of Surgery, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
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Abstract
Dialysis access failure is a major cause of mortality and morbidity among dialysis patients. Preservation of access is critical to maintaining hemostasis, avoiding uremia, and managing the complications of kidney failure. While angioplasty remains the most common method of managing arteriovenous (AV) access stenoses, the use of stents and stent grafts to manage venous stenoses associated with AV access has become more prominent. There have been several prospective randomized trials that have demonstrated the benefit of these devices in maintaining the target lesion patency of the treated areas. In this article, the author reviews the data relating to stent and stent-graft use at the venous anastomosis and outflow veins for pseudoaneurysms of grafts, at the cephalic arch, and for central venous stenoses.
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Affiliation(s)
- Gordon McLennan
- Department of Radiology and Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio
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42
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Agarwal AK. Endovascular interventions for central vein stenosis. Kidney Res Clin Pract 2015; 34:228-32. [PMID: 26779426 PMCID: PMC4688584 DOI: 10.1016/j.krcp.2015.10.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 10/11/2015] [Indexed: 11/28/2022] Open
Abstract
Central vein stenosis is common because of the placement of venous access and cardiac intravascular devices and compromises vascular access for dialysis. Endovascular intervention with angioplasty and/or stent placement is the preferred approach, but the results are suboptimal and limited. Primary patency after angioplasty alone is poor, but secondary patency can be maintained with repeated angioplasty. Stent placement is recommended for quick recurrence or elastic recoil of stenosis. Primary patency of stents is also poor, though covered stents have recently shown better patency than bare metal stents. Secondary patency requires repeated intervention. Recanalization of occluded central veins is tedious and not always successful. Placement of hybrid graft-catheter with a combined endovascular surgical approach can maintain patency in many cases. In the presence of debilitating symptoms, palliative approach with endovascular banding or occlusion of the access may be necessary. Prevention of central vein stenosis is the most desirable strategy.
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Affiliation(s)
- Anil K Agarwal
- Section of Nephrology, University Hospital East, Columbus, OH, USA; Interventional Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Abstract
The implantation of Long-Term Central Venous Catheters (LTCVC) in cancer patients has been essential to conduct the oncological treatments of today. The complexity of the protocols requires accuracy on the management of such devices in order to keep them long-functioning. The article focuses on such subject from an oncological perspective, pointing out threats of the disease to the central venous system (CVS) and the ways to face them successfully. The most salient points related to surgical techniques and the insights to follow-up long-term inserted catheters are discussed. An anatomical classification is suggested to help understand occurrence of malpositions and to north the necessary maneuvers of repositioning. Such matters are based on 3000 LTCVC-placements performed by the author at the Brazilian National Cancer Institute (INCA) between 1999 and 2011. As nearly 30% of the patients presented some sort of anatomical disorder at the moment of the surgery, it was judged worthy to address such experience to those young surgical oncologists willing to tackle LTCVCs in Cancer Units.
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Effect of Central Venous Angioplasty on Hemodialysis Access Circuit Flow: Prospective Study of 25 Symptomatic Patients. J Vasc Interv Radiol 2015; 26:984-91. [DOI: 10.1016/j.jvir.2015.03.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 03/08/2015] [Accepted: 03/11/2015] [Indexed: 11/20/2022] Open
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Krycińska R, Trznadel A, Kuchalska P, Lis M, Dołęga-Kozierowski B, Dyś K, Drelichowski S, Witkiewicz W. Brachiocephalic Vein Stenting and Body-Floss Technique as a Treatment of CVD in Dialysis-Dependent Patient - Case Report and Literature Review. Pol J Radiol 2015; 80:247-51. [PMID: 26000070 PMCID: PMC4432621 DOI: 10.12659/pjr.893358] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 02/23/2015] [Indexed: 11/24/2022] Open
Abstract
Background Given the increasing number of elderly hemodialysis-dependent patients with concomitant chronic diseases the successful creation and maintenance of reliable vascular access become a real challenge. In current literature central vein disease (CVD) is defined as at least 50% narrowing up to total occlusion of central veins of the thorax including superior vena cava (SVC), brachiocephalic (BCV), subclavian (SCV) and internal jugular vein (IJV). The incidence of CVD has been reported to be as high as 23% in the total dialysis population and 41% in those with access related complains. Case Report 61-year-old man has been admitted to the local radiology department with symptoms of the superior vena cava syndrome. The venography revealed occlusion of the right brachiocephalic vein. Due to Tortuosity and lack of stamp of right subclavian vein contributed to the decision to perform recanalization by “body floss” technique. In a further step we have performed PTA of obstructed vein segment using 7×40 mm balloon. Due to the presence of residual stenosis it was decided to implant two self – expanding stents 10×40 mm. After the procedure the patient was discharged in good condition and transferred to dialysis center. Conclusions Main objective was the salvage of a functioning arteriovenous fistula. Performed endovascular intervention is a safe and effective approach to correct CVD for a short term. To ensure long lasting effects the patient will require enhanced follow-up and inevitable reinterventions. For that matter, prevention of CVD remains critical.
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Affiliation(s)
- Róża Krycińska
- Lower Silesian Centre for Diagnostic Imaging, Hospital to the Wrocław Centre for Research and Development, Wrocław, Poland
| | - Agata Trznadel
- Lower Silesian Centre for Diagnostic Imaging, Hospital to the Wrocław Centre for Research and Development, Wrocław, Poland
| | - Paulina Kuchalska
- Lower Silesian Centre for Diagnostic Imaging, Hospital to the Wrocław Centre for Research and Development, Wrocław, Poland
| | - Michał Lis
- Lower Silesian Centre for Diagnostic Imaging, Hospital to the Wrocław Centre for Research and Development, Wrocław, Poland
| | - Bartosz Dołęga-Kozierowski
- Lower Silesian Centre for Diagnostic Imaging, Hospital to the Wrocław Centre for Research and Development, Wrocław, Poland
| | - Krzysztof Dyś
- Lower Silesian Centre for Diagnostic Imaging, Hospital to the Wrocław Centre for Research and Development, Wrocław, Poland
| | - Stanisław Drelichowski
- Lower Silesian Centre for Diagnostic Imaging, Hospital to the Wrocław Centre for Research and Development, Wrocław, Poland
| | - Wojciech Witkiewicz
- Lower Silesian Centre for Diagnostic Imaging, Hospital to the Wrocław Centre for Research and Development, Wrocław, Poland
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Trerotola SO, Kothari S, Sammarco TE, Chittams JL. Central Venous Stenosis Is More Often Symptomatic in Hemodialysis Patients with Grafts Compared with Fistulas. J Vasc Interv Radiol 2015; 26:240-6. [DOI: 10.1016/j.jvir.2014.10.048] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 10/22/2014] [Accepted: 10/29/2014] [Indexed: 11/25/2022] Open
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Simulation of Dialysis Access (SoDA) – Eight Stations Hands-On Dialysis Access Simulation. J Vasc Access 2014. [DOI: 10.5301/jva.2014.12710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Leontiev O, Shlansky-Goldberg RD, Stavropoulos SW, Mondschein JI, Itkin M, Clark TW, Trerotola SO. Should All Inflow Stenoses Be Treated in Failing Autogenous Hemodialysis Fistulae? J Vasc Interv Radiol 2014; 25:542-7. [DOI: 10.1016/j.jvir.2013.12.566] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 12/20/2013] [Accepted: 12/21/2013] [Indexed: 11/16/2022] Open
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Tessitore N, Bedogna V, Poli A, Lipari G, Pertile P, Baggio E, Contro A, Criscenti P, Mansueto G, Lupo A. Should current criteria for detecting and repairing arteriovenous fistula stenosis be reconsidered? Interim analysis of a randomized controlled trial. Nephrol Dial Transplant 2013; 29:179-87. [PMID: 24166470 DOI: 10.1093/ndt/gft421] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The vascular access guidelines recommend that arteriovenous fistulas (AVFs) with access dysfunction and an access blood flow (Qa) <300-500 mL/min be referred for stenosis imaging and treatment. Significant (>50%) stenosis, however, may be detected in a well-functioning AVF with a Qa > 500 mL/min, too, but whether it is worth correcting or not remains to be seen. METHODS In October 2006, we began an open randomized controlled trial enrolling patients with an AVF with subclinical stenosis and Qa > 500 mL/min, to see how elective stenosis repair [treatment group (TX)] influenced access failure (thrombosis or impending thrombosis requiring access revision), or loss and the related cost compared with stenosis correction according to the guidelines, i.e. after the onset of access dysfunction or a Qa < 400 mL/min [control group (C)]. An interim analysis was performed in July 2012, by which time the trial had enrolled 58 patients (30 C and 28 TX). RESULTS TX led to a relative risk of 0.47 [95% confidence interval (CI): 0.17-1.15] for access failure (P = 0.090), 0.37 [95% CI: 0.12-0.97] for thrombosis (P = 0.033) and 0.36 [95% CI: 0.09-0.99] for access loss (P = 0.041). In the setting of our study (in which all surgery was performed as in patient procedure) no significant differences in costs emerged between the two strategies. The mean incremental cost-effectiveness ratio for TX was €282 or €321 to avoid one episode of thrombosis or access loss, respectively. CONCLUSIONS Our interim analysis showed that elective repair of subclinical stenosis in AVFs with Qa > 500 mL/min cost-effectively reduces the risk of thrombosis and access loss in comparison with the approach of the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines, raising the question of whether the currently recommended criteria for assessing and treating stenosis should be reconsidered.
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Affiliation(s)
- Nicola Tessitore
- Department of Medicine, Renal Unit, University Hospital, Verona, Italy
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Agarwal AK. In reply to 'The other side of the central vein stenosis story'. Am J Kidney Dis 2013; 62:1018. [PMID: 24157273 DOI: 10.1053/j.ajkd.2013.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 08/21/2013] [Indexed: 11/11/2022]
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